‘In Dialogue’ Episode 7: Dr. Ritika Goel

Introduction:
CPSO presents “In Dialogue” podcast series, where we speak to health system experts on issues related to medical regulation, the delivery of quality care, physician wellness, and initiatives to address bias and discrimination in health care.

Dr. Saroo Sharda (CPSO Medical Advisor / EDI Lead) (SS):
Hi and thanks for joining us “In Dialogue.” My name is Dr. Saroo Sharda. I’m a practicing anesthesiologist, in addition to my roles as a medical advisor, and Equity, Diversity and Inclusion Lead at the CPSO. I hope you enjoy this episode.

Hi Ritika. It is so lovely to be in conversation with you today. And I want to thank you for taking the time to chat with us today. I know you in various realms and in your various roles. But could you introduce yourself as a clinician and also just let folks know what some of your other roles are at the university, and some of the clinical contexts in which you work as well?

Dr. Ritika Goel (RG):
Yeah, definitely. Thank you so much for having me to speak about these really important issues. So, I’m a family physician. I work in an academic Family Health Team in Toronto. I do teaching in that context and my practice is primarily focused on serving various marginalized communities. That’s my main practice. And then I also work with a shelter-based practice. So, that’s with St. Michael’s Hospital and then with Inner City Health Associates, and the shelter is an exclusive space for a women-identified people, so we serve women and trans and non-binary folks, exclusively. And it’s both a shelter and a drop-in centre.

In those two spaces, I see disproportionately folks that are experiencing homelessness, people who use drugs, people with severe mental illness, as I mentioned we treat a handful of trans and non-binary folks, as well as people that are impacted by immigration in various ways. So that could be new immigrants, refugees, refugee claimants, undocumented people, etc. So, serving a number of communities and, of course, disproportionately folks who are racialized, Indigenous folks, etc., in those spaces.

SS: Okay, so I think that’s actually one of the reasons that we wanted to talk to you because you do have this practice where you’re taking care of people who have lots of intersecting identities. And you talked about this is a shelter for women-identifying folks, which may include trans folks or non-binary folks as well. Can you talk to us a little bit about what you have noticed in terms of some of the barriers that patients face, particularly when they have those intersecting identities — so, women who are maybe also new to Canada as refugees or immigrants, women who are racialized — tell us a little bit about what your observations have been as a clinician taking care and being in community with those folks.

RG: When we’re interacting with patients, as clinicians I think we often have to think about how their identities shape their lives and their experiences in terms of what structures they come into contact with in this world. So, by definition, interacting with a racialized woman, or an undocumented woman, or a trans or non-binary person, means that they will be impacted differently by the structures that exist in society. So, the immigration system, for example, and how it impacts disproportionately Black and Latinx women and their experiences; where being undocumented is sort of one of the most defining factors of their experience; where they’re denied access to basic services, often denied access to health care unless they can find it at very specific places.

I think about really all women that have the experience of motherhood, interact with potentially systems like child welfare. But again, we see a disproportionate impact on those who are Black and Indigenous in a very stark manner. The justice system — I have a number of patients who’ve been incarcerated and we know that again, in Canada, the numbers are disproportionate for Black and Indigenous women in terms of who has faced incarceration, how they’re viewed by police and by the justice system — is something I think about a lot, particularly working with people with mental illness, where we may have to certify people against their will. What that means to call 9-1-1, and have police come and interact with somebody who may be much more unsafe when interacting with police than somebody who doesn’t hold a specific marginalized identity. So, I think it’s thinking about what do those identities mean, just in broader society? And what are the structures that exist that we, as clinicians, come into contact with? And, of course, those have disproportionate impacts on different people based on their identities.

SS: Thanks so much Ritika for really outlining the structures, because I think sometimes that conversation or that really important theoretical underpinning gets missed when we’re talking about interpersonal interactions. And often when we’re talking as healthcare practitioners about how can we do better by our patients, it’s not that we’re necessarily saying that we are bad people or that we are biased people or discriminatory people, but really recognizing that we sit within these bigger systems, which ultimately, unknowingly or knowingly, affect how we then interact with the people that we care for. And I really like how you outlined that in the examples that you use of the justice system.

Can you give a few examples of health care where you’ve been trying to maybe access certain health care for your patients or examples where you’ve noticed, maybe particularly in the pandemic, that also help us to understand those structures that affect certain people disproportionately?

RG: Yeah, the pandemic has, for people that were already living on the margins, has really just magnified everything. Where access was already an issue, whether we’re talking about health care services or social services, now access for everything really has been substantially more difficult. So, even working in a space like a women’s shelter/drop-in, which is supposed to be there and low-barrier and available for people to drop-in to access services, many of those spaces have had to close their doors because of the pandemic, or many of those spaces have had to be much more regimented in certain ways, like having to screen people, having to enforce masking. These are things that can be really difficult for people who are marginalized to understand, to go ahead with, particularly folks who may have mental illness, where they may not understand the reason for certain things. You may also have experiences with carceral systems, for example, where they’re used to their behaviours being policed. So, we’re seeing that show up in healthcare, as well.

A great example would be a major shift to virtual care. For people who have a language barrier, or who have a developmental delay, or who have major trust issues because of their negative experiences in the past, interactions through virtual care can often be very alienating, and can be very difficult to connect with the provider, can be difficult to really convey all of your concerns. Quite early on, I started to see a very clear pattern, where many of my most marginalized patients were the ones who I was losing touch with because I couldn’t reach them over the phone. If they showed up at our doors, maybe they weren’t allowed to walk in anymore without an appointment, which may be something they’re used to being able to do to access my services. And we found also that we were having difficulty accessing the specialist care that we were referring people to because of the transition to virtual, which again, was hard for some folks who don’t have phones, or because things would get canceled or delayed, and then once that happens, it’s just that much harder to re-engage somebody where it was already difficult for them to make an appointment. We’ve also seen with many cancellations, a lot of times it can be left up to the patient to advocate for themselves to really kind of get back into the system and when we spent a lot of effort advocating for somebody to get into the system, and then they once again fall out, it really makes me concerned that when we’re picking the pieces back up, who was able to get back in the door is going to be disproportionately those who can advocate for themselves.

Similarly related to vaccines, there have been many references to “vaccine Hunger Games,” and you can tell that, again, I could see a very clear difference, even in my shelter practice versus my family health team practice or in the family health team, those who are more marginalized versus those who aren’t in terms of who had a first dose when and who had a second dose when and who required a little bit more information to be able to access such a beneficial service. So, there’s umpteen examples, really everything about the pandemic has worsened situations for people who are intersectionally marginalized in various ways.

SS: I think what you’re saying about vaccines, too, has also come out in the vaccine hesitancy narrative with a lot of people assuming that every person who is unvaccinated is inherently anti-vax, when actually we may not realize unless we’re embedded in these communities as you are, is that sometimes it’s an access issue, or it’s a deep distrust of healthcare systems, which have actually harmed certain communities historically, and in an ongoing way. So, I think you delineating this from your experiences of being in community and working with these communities is really, really helpful for us to start to understand those structures a little bit better.

I want to move on to you a little bit if that’s okay? You are literally juggling many things in this very moment. But tell us a little bit about some of your greatest joys as a woman in medicine and some of your greatest challenges. And again, I know that you have intersecting identities as a woman of colour and other identities, I’m sure. So, can you tell us a little bit about a) the joys, b) the challenges and c) how your own identity has shaped and influenced some of those joys and challenges in your journey?

RG: There are so many joys of being a woman in medicine, as a racialized woman and as an immigrant. I think my ability to impact and serve marginalized communities is very great, and I see that and I feel that very deeply. Anytime that I bring in a South Asian woman who has never had a pap smear before, and I’m able to explain that to her in her language. And I’ll talk to her about how new immigrants, South Asian women, disproportionately have not had cervical cancer screening, and what that’s about and what it means and why it’s important. And I see also in them, how they may feel that they can trust that information coming from me, but also the procedure being literally in my hands, the difference that that makes because of that trust, as you said. So, that’s a very specific example, serving South Asian women that are sort of like me, people that speak the same language, etc. But I think there’s also just a broader piece, like I find that there’s a translation often when you’re a woman being able to serve other women, or when you’re a racialized person being able to serve other racialized people or an immigrant, right? I think people understand a shared experience, so that for me is a great joy.

Also, I think connecting with other folks who are doing similar work that we’re fortunate, I think, in Toronto, but I think just in general, in Canada, in medicine, there has been a sea change in the past 10 years. And there’s so many people that are really dedicating their lives and their careers to serving marginalized communities, and thinking in very creative ways about how to do that. For example, folks who are serving to provide safe supply, which can be seen as a controversial practice, but I know firsthand has been life saving for so many of my patients. So, seeing our unique ability to use some of the power that we do have as physicians with a particular window into particular challenges because of our identities. ([speaking to baby] Someone has things to say.)

SS: You gave a really beautiful answer on the joys, do you want to move on to the challenges?

RG: You can’t separate out the idea of being a woman in medicine, or a racialized woman in medicine, from just being a racialized woman in the world, in a way. Sometimes these things are hard to pinpoint. But what we know is that as you go up in leadership in medicine, leadership gets whiter and maler, we know that. And that’s probably also true for other things around abilities, sexual orientation, gender identity, religion, I’m sure there’s some pieces there as well. So, I think that’s a reality that we all live in, part of the challenge is just sometimes not really knowing.

And then the other piece is just a structural challenge, right. So as much as we, I think in medicine, are trying to make some changes in terms of how we see representation and how we recognize different people’s work, we largely still have a very meritocratic-based system where the assumption is that everybody has the same access, and everybody has the same time available to them, when we know, I think mothers particularly, have pregnancies and have maternity leaves and have disproportionate childcare responsibilities that just, by definition, get in the way of being able to publish papers, etc. And those things are not seen and they’re not recognized, I think, in a meaningful way, where we actually really think creatively about how we value people and we value people’s work. That being said, I think I’m very fortunate to work in many spaces where there has been a lot of support. And I think trying to think creatively about these things as well, we’re definitely not there yet in medicine at large.

SS: Can you maybe give some examples of what those creative solutions might look like? I think you’re right; we have a long way to go and really thinking about what is valued — what is even valued in terms of tenure and promotion and for people on an academic track? But also, what is valued in terms of where women physicians often spend their time and the type of work that they’re doing? And is that remunerated or is that rewarded in whatever way is equitable? So, what are some of the things that you have seen that you think have been good creative ways by organizations or structures? And what would you like to see?

RG: One of the ways that we see marginalization and oppression manifests itself through structures is that the people who make the rules are the ones who disproportionately benefit from the structures and from the rules. I think a great example of this in medicine is the fee-for-service system. And there has been really good work done by folks looking at what fee codes, first of all, serve women. So, even just looking at certain services that are usually for women versus usually for men, but also in services that are provided by physicians that are disproportionately female versus disproportionately male. So, thinking about counseling services versus surgical services, for example. And I think about all of the ways in which as a fee-for-service family physician, which I’m not, you would be incentivized to do certain things over other things, and how many of the things you’re incentivized to do often don’t actually really get to the root of what people need. For example, in primary care, you might be incentivized to have somebody only speak about one issue, when, in fact, those who have complex needs, who are marginalized structurally, etc., might actually need you to be able to hear many things at one time. So, that’s about how this impacts our patients.

But also, we know that given that scenario, women are more likely to just take the extra time, and are more likely to then take a pay cut as a result. Part of the solution is really just having women and racialized people and people with disabilities, people with varying identities at the table, at the decision-making tables, because you can’t really see how things impact these communities if you’re not part of them. And in fact, you may see the opposite — you may see how things would actually disproportionately impact you as a person who’s more privileged. So, having women at the table is really key. I think as much as we know maternity leave and pregnancies and childcare, etc., these things disproportionately impact women and their careers, I think creating space for them and allowing women to have those spaces is still really, really important. So, the solution is not just pretending those things don’t exist.

I’ve been fortunate to work in places where there isn’t a blink at the idea that I’m taking a year off and have done with both my kids. But I know that that’s not the experience that every woman in medicine has. And I think there’s work to be done, probably more in certain areas in medicine than others. Just having an across the board understanding that we support women and parents in being able to take leave, whether that’s for just childcare responsibilities once the children are here and just part of your life, or whether it’s around parental leave, but then also taking a critical view to who’s in leadership, and how does that change their lens? And how do we promote having more equity and diversity in our leadership? How do we even if we don’t have that, then just make sure that we’re bringing that lens to policies that we have? So, there’s a lot of work being done — but again, there’s also lots of work to do.

SS: I think you’re absolutely right. And certainly, my experience of being a mother in medicine and maternity leaves, and in the perioperative domain was very different. And I think also, assuming that as a woman in medicine speaking up is safe, I think is also part of what some of these structural issues are — that, oh, if you had a problem being in that situation, you should have just said something — and recognizing that that’s not actually always safe, particularly for those of us that at that point may have been more junior in our career, there’s a whole myriad of things that go into that. And I think the point you make about diversity of leadership is really important. And also, that those voices that do get invited to the table are actually heard, so not just that they’re at the table, but they’re actually heard at the table. So, thanks for that.

I want to talk a little bit about something you touched on there at the go, which is, if we’re not at the point yet of having that diversity of leadership, how do we bring those lenses. And I think part of that is kind of this conversation around allyship. And allyship can again, be kind of interpersonal allyship, it can be structural, it can be organizational. So, can you talk a little bit about the types of allyship that you have experienced as a woman in medicine, the type of allyship you’ve provided as somebody who works in solidarity with communities and where you think folks need to go — particularly folks who do have more power and privilege in the system — how can they in concrete ways use that to be good allies to influence policy to take these important lenses?

RG: Very good questions. I think there’s a number of different pieces there. So, there’s how can we engage in allyship or solidarity, which is my preferred term, towards the communities we serve? And remembering that, regardless of the identities we hold, we all hold a tremendous amount of power as physicians in society, just broadly and in our day-to-day, and being able to influence people’s lives and care at incredibly vulnerable moments in their lives. I think as physicians, just broadly, being able to understand that and reflect on that is really important. I see daily how my patients experience violence at the hands of the health care system, from people that are probably not in any way trying to inflict that kind of violence on them. And I use the term violence to talk about sort of dismissing people’s concerns, not giving them access, etc. I think the bigger thing that really all of us can do is just develop a better understanding of power, of our positionality, meaning where do we sit in a given space, in a given room, in a given interaction? So, my interaction with a patient has a very particular power relationship relative to, for example, in a meeting among physicians. So thinking about that, and then thinking about how — there’s a great quote from author Ijeoma Oluo, where she talks about, essentially, your point of action is where your power or privilege intersects with somebody else’s oppression. So, thinking about where that is.

I have a really good understanding of what it is that women might need, or what it is that immigrants might need, because I have those experiences. But I don’t always have a great understanding of exactly what trans and non-binary people need, or what people with disabilities need, etc. So, being able to recognize your own blind spots is a huge part of allyship and solidarity, and then bringing in those people, centring those voices, uplifting those voices, and then actually taking leadership from those voices, and not having that be something that’s just done as a checkbox. I think that’s the really important part of the equity 2.0 journey. Because I think right now, we’re starting to have much more of the conversation around equity in medicine, much more than we did even just a few years ago. But actually translating that into real things means being willing to listen to the people directly affected and centre them and take leadership from them.

SS: I love what you’re saying there in terms of it’s not just about bringing them in and listening, but it’s also then about taking leadership from them. And I think that’s so crucial and where we kind of need to be. And you’re right, I don’t think we are really there yet in many healthcare organizations. So, you talked a little bit, Ritika, about the multiple pieces that women are often trying to juggle, whether that’s women in medicine or your patients. And again, like I said, you’re literally juggling this very cute bundle right now. So how has that, do you think, affected — and I’m going to talk specifically now about women in medicine — how has that affected our ability to care for our patients, when we ourselves may be kind of not functioning optimally? We’re hearing about a lot of increased rates of burnout right now and we know that that disproportionately affects women in medicine. So, what has been your experience of that? And particularly, I think the ability of a well physician versus an unwell physician providing good, high quality patient care?

RG: I think you want to focus on medicine, but I will say this is a broader issue with society at large, as well. Medicine is a microcosm of society and part of what happens is that in the world of work, we don’t acknowledge what happens outside of the world of work. So, that disproportionate burden of childcare, but also elder care, just care work in general, disproportionately falls on women and what that does to women’s capacities to bring their whole selves to work is impacted.

So, I think being able to better understand that philosophically, just in general as sort of a sea change in how we approach these things, but also in our actual policies as we were just discussing, is really important. I think normalizing having babies on camera during interviews, if that’s what somebody wants, to kind of not invisibilize that work, right to not invisibilize the influence of children, the influence of caring relationships, etc., is really important. And then that means that we’re then able to recognize the whole experience for a particular individual, as opposed to kind of saying, well, this person is burnt out, but that person is not, which makes it about the person. We see a lot of that kind of assumption of assigning blame to people who actually are just navigating a lot more and are juggling a lot more because of their disproportionate related responsibilities. So, I think normalizing that conversation happening in the workplace, instead of just assuming that we’re all just supposed to take care of our stuff outside of the workplace and not really ever talk about it or have it be seen is important.

SS: And I love what you just touched on there about burnout being an individual responsibility, and while that person is burnt out and that person isn’t and they do the same job, therefore, there must be something wrong inherently with that person, rather than actually looking, as you say, at the whole person. And again, coming back to what you talked about a lot, which I really appreciate, the structures in which some work is invisible, and some work is important, some work is not important enough, etc. I love that you have delineated that for us a little bit.

I’m going to ask you a question about your work with students because you have a role at the University of Toronto in the medical school. We mentioned earlier that you’ve already seen some changes start to happen in the last few years around these equity conversations, around social accountability, but this is really your area of focus at the University. I’m interested to know how you think that physicians who’ve actually been out in practice for some time who didn’t necessarily have a Social Accountability Lead when they were at medical school, who didn’t you know, think about equity and power and cultural humility and all of the things that are starting to become part of the medical education curriculum. What are some of the other things physicians can do when they listen to this kind of conversation and they just feel like I just don’t know where to begin? How would you suggest that physicians approach this?

RG: I have a lot of empathy for people in that situation. One thing about understanding how structures work and how they’re created is recognizing that this comes about because sexist narratives and racist stereotypes and thinking about able-bodied people as being the norm, these are part of the narratives that we’re all steeped in, this is the air that we breathe. So, for people who have been raised where their formative years or their training, etc., was at a time when really, in the broad mainstream milieu, we we’re not questioning these assumptions, it’s understandable that it would be difficult to shift your understanding or shift your frame, especially if those are not your own lived experiences or identities.

I think we need to be able to have these conversations, that’s the most important thing is we need to be able to have brave spaces as they talk about and be able to push people — with compassion — but push people to think about things, to really have that kind of transformative learning happen. And I think it’s on our institutions to be able to support such conversations. I don’t think it helps for us to essentially pretend this is not happening. And so, I think, yes, medical education, and I have a role that has to do with students and residents at U of T, is important. But I think, also, continuing professional development and faculty development, etc., where people who are already in practice are given an opportunity — ideally with other people who are going through a similar thing, because there’s also community to be built in just all of us collectively unlearning, right? I think we’re all collectively unlearning every day, because our day-to-day lives teach us one version, we have to remember that actually, that’s not how things work. So, creating those spaces, coming at them with compassion and non-judgment, while also maintaining accountability, is where we need to be headed.

SS: Thank you so much — to both of you — for spending time with us. And I love that carrying compassion and accountability together, I think that’s such an important for us to think about. So, on that beautiful note and thinking about holding those complexities together as we all move forward and learn and unlearn in this work, we just want to thank you so much and just invite you to say anything to close.

RG: I’m just so glad that we’re having these conversations. I’m glad that there are increasingly, I think, people in our institutions that are charged with helping us, as a profession, think about these things. We can only all be the better for it. And ultimately, hopefully, that really benefits patients and our communities.

SS: Thank you both for your time. We really, really appreciate it.

Closing:
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